use of logos, pathos, ethos for persuasion in cancer pamphlets€¦ · as for infectious diseases,...

The Internet Journal Language, Culture and Society URL: http://aaref.com.au/en/publications/journal/ ISSN 1327-774X

© LCS-2020 3 Issue 49

Use of Logos, Pathos, Ethos for Persuasion in Cancer Pamphlets

Associate Professor Dr Su-Hie Ting* Myra Ungau

Dr Collin Jerome

Faculty of Language and Communication, University Malaysia Sarawak, 94300 Kota Samarahan Sarawak, Malaysia. Tel: +60-82-581760. Fax: +60-83-581781

*Corresponding author:[email protected]; [email protected]

Abstract

In view of the lack of findings on persuasive strategies used in health risk messages, the study exam-ined the use of logos, pathos, and ethos for persuasion in cancer pamphlets. Using Aristotle’s (1954) rhetorical appeals, qualitative content analysis was conducted for 10 cancer pamphlets disseminated in Malaysia. The analysis revealed an over-reliance on logos (96.73%) while pathos and ethos are rarely used. The pamphlets offer dense information on the location of the cancer, symptoms, inci-dence, risk factors, preventive measures, early detection, and treatment. Pathos appears in the form of a call to save their lives from the killer on six of the cancer pamphlets but there is lack of information on disease severity. The near absence of the emotional appeal may lessen urgency of cancer screen-ing. The ethos appeal lies in the name of the government agency, lending authority to the pamphlet. The paper offers suggestions on how emotional and ethical appeals can be incorporated in cancer risk messages to increase persuasiveness.

Keywords: Logos; pathos; ethos; rhetorical appeal; persuasion; cancer; health risk messages

Introduction

Researchers have investigated how persuasive strategies are used in advertisements to persuade potential customers to buy products and services (Ab Rashid et al., 2016; Emanuel, Rodrigues, & Mar-tins, 2015; Nair & Ndubisi, 2015) and also in e-business website designs (Winn, 2000) and found that the most frequently used persuasive appeal is pathos (emotional appeal). For example, Nigerian scam messages appealed to pity and tapped into human desires and needs to deceive recipients (Naksawat, Akkakoson, & Loi, 2016).The other two rhetorical appeals are logos (logical appeal) and ethos (appeal to credibility) (Aristotle, 1954). All three rhetorical appeals are used by presidential can-didates to persuade their electorate to vote for them (Androniciuc, 2016; Mori, 2016; Mshvenieradze, 2013).

Although the use of rhetorical appeals has been extensively studied in advertisements and political speeches, few studies have been conducted on the use of persuasive strategies in health risk mes-sages. Health risk messages persuade the public to adopt preventive and cure measures to protect themselves against diseases. In the United States, Chen et al. (2015) found that disease versus hu-man agency assignment (“Cancer developed in me” versus “I developed cancer” respectively) do not affect perceived severity of colon cancer. However, messages highlighting human agency leads to higher perceived susceptibility to colon cancer. When temporal agency is attributed to humans (“I am approaching death”) rather than to death (“Death is approaching me”), the cancer risk message was more persuasive but only when the story was told in a first-person viewpoint. Chen et al. (2015) con-cluded that all eight versions of the magazine articles on colon cancer did not undermine the partici-pants’ perceptions of self- and response-efficacy and were very persuasive in heightening participants’ intention to make lifestyle changes to prevent cancer. Chen et al.’s (2015) results contradicted findings on threat posed by bacteria (Bell et al., 2014a), viruses (McGlone et al., 2013), and radon gas (Bell et al., 2014b), showing that people respond differently to cancer risk messages. Cancer risk messages

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© LCS-2020 Page 14 Issue 49

have their particular slant of framing due to uncertain treatment outcomes and causes which are not definitive. As an example, the early symptoms of nasopharyngeal cancer are often missed because they are usually nonspecific and resemble less serious conditions (Tabuchi et al., 2011). Greater awareness of cancer may lead to earlier diagnosis and reduce deaths. The provision of educational information (most often in print form) is considered to be a fundamental prerequisite of consumer par-ticipation in health care (Currie et al., 2001).

Thus far, in Malaysia researchers have found that different appeal strategies are used in health risk messages for infectious diseases and cancer (a non-communicable disease). Jerome and Ting’s (2017) analysis of hospital posters on cancer revealed that the distressing images of symptoms of cancer extend and complement textual information. The cancer posters use the fear appeal to evoke strong emotional responses. Guilt and pity appeals are also used to make smokers feel guilty about causing hurt to their loved ones. The cervical cancer poster targeted at women stands out in that it has an extension-contrast text-image relation where the image of a beautiful yellow orchid is used to con-trast the grim mortality rate. As for infectious diseases, Ting and Jerome (2017) found a strong reli-ance on logical appeal and a near-absence of emotional appeal in airport banners. The banners on Ebola, Middle East Respiratory disease and other infectious diseases are informative on risk groups, symptoms and recommended actions. Only one out of nine airport banners use pathos to motivate the targeted audience to take recommended actions to prevent the spread of hand, foot and mouth dis-ease (“Sayangi anak anda, cegah Penyakit Tangan, Kaki dan Mulut”, translated as “Love your child, prevent Hand, Foot and Mouth Disease”). Ethos is in the form of the logo and name of the health min-istry (national and state level) which produced the banners. Unlike the cancer posters, the airport ban-ners on infectious diseases used positive appeal to motivate passengers to take preventive measures. Positive appeal is not as persuasive as negative appeal in health messages (Robberson & Rogers, 1988).

Considering that responses to cancer risk messages differ from those of other diseases (Bell et al., 2014a, 2014b; Chen et al., 2015; McGlone et al., 2013) and the framing of cancer risk messages also differ from that of infectious diseases (Jerome & Ting, 2017; Ting & Jerome, 2017), more studies are needed to understand disease framing, particularly in pamphlets. Pamphlets are the media of choice when health care organisations provide textual information about a health care topic (Kline & Mattson, 2000). A review of the effectiveness of print materials found that pamphlets can be effective in chang-ing knowledge, attitudes and behaviour in relation to a wide range of health-related issues (Paul & Redman, 1997). However, little is understood about the types of information included in pamphlets on diseases or the persuasive strategies used to convince the audience to take preventive or cure measures to protect themselves from the disease.

This study seeks to examine the use of logos, pathos, and ethos for persuasion in cancer pamphlets produced by health authorities in Malaysia.

Method of study

A descriptive approach was used, where qualitative content analysis for rhetorical appeals was con-ducted for cancer pamphlets produced by the Ministry of Health (MOH) Malaysia, National Cancer Council (Majlis Kanser Nasional, MAKNA), and Cancer Institute Malaysia (CIM). The 10 pamphlets on cancer were on lung cancer, prostate cancer, colon cancer, breast cancer, lymphoma, mouth cancer, leukaemia, nose and throat cancer, and cervical cancer. There were two different pamphlets on cervi-cal cancer but only one pamphlet each for the other cancers.

The 10 cancer pamphlets were obtained after an exhaustive search. The printed pamphlets were tak-en from Sarawak General Hospital, Normah Medical Specialist Centre, Kuching, and Borneo Medical Centre Kuching, whereas the digital versions were downloaded from MOH, MAKNA and CIM web-sites. “Information that is legally accessible to the public and appropriately protected by law does not require ethics review. Publicly available information is any existing stored documentary material, rec-ords or publications, which may or may not include identifiable information according to the TCPS (Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans)” (University of Waterloo, n.d.). Furthermore, the intention to analyse these pamphlets were made known to a Ministry of Educa-tion committee during a grant progress report meeting, and their only request was to share the find-ings with the Ministry of Health.



The first (S.T) and second (M.U) researchers read the cancer pamphlets to identify the presence of logos, pathos and ethos, with reference to the analysis framework (Table 1). Each time a rhetorical appeal appeared in a phrase or sentence; it was counted as one instance. For example, “Recent re-search has found ...” constituted one instance of the logos appeal. Based on the total number of logos, pathos and ethos appeals identified in each pamphlet, percentages for the reliance on the logos ap-peal were computed (Table 1). Percentages for the pathos and ethos appeals were not computed be-cause of the low incidence.

Table 1: Framework for analysing logos, pathos and ethos appeals in health risk messages

Appeal Definition Indicator

Logos A logical appeal which stresses logic and reason (Aho, 1985; Green, 2004) using numerical data and facts as proof (Hig-gins & Walker, 2012, p. 198; Holt & Mac-Pherson, 2010).

Linguistic links such as “initially”, “later” and “fi-nally” to enhance arguments (Mshvenieradze, 2013).

Pathos An emotional appeal to the audience’s feelings such as happiness, sadness, satisfaction, pity, or fear (Aho, 1985).

Metaphors or adjectives that tap into security, love, guilt, greed and humour (Gabrielsen & Christiansen, 2010), anger, insult, empathy, and confusion (Mshvenieradze, 2013).

Pronouns such as “we” and “you” to identify with the needs, values and desires of the audi-ence (Higgins & Walker, 2012).

Ethos An ethical appeal anchored to the perso-na or projected character of a communi-cator (Conrad & Malphurs, 2008; Demirdöğen, 2010; Hartelius & Browning, 2008). The credibility and trustworthiness of the communicator are highlighted to convince the audience of the authority of the message (Higgins & Walker, 2012).

Information on the communicator’s intelligence, character, and goodwill (Connors, 1979), au-thority, marital status, and social status during a discourse.

Results and Discussion

This section begins with results on the frequency of rhetorical appeals in cancer pamphlets and illus-trates the use of the appeals in two pamphlets (Figures 1 to 5 in the Appendix).

Frequency of logos, pathos and ethos in cancer pamphlets

Table 2 shows that the cancer pamphlets rely on the use of the logos appeal (average of 96.73%). The percentage of factual and numerical information in the cancer pamphlets ranged from 92% (mouth cancer, MOH) to 98.48% (cervical cancer, CIM). On average, the pathos and logos appeals accounted for only 1.37% and 2% of the rhetorical appeals used in the cancer pamphlets, showing an under-use of potentially effective means to motivate the audience to undertake health protective ac-tions. Next, the types of information that are used to achieve the three types of persuasive appeals are described.



Table 2: Frequency of information is presented using logos, pathos and ethos in cancer pamphlets

Type of cancer Source of pamphlet

Logos Pathos Ethos Total Reliance on logos

Cervical cancer (#1) CIM 65 0 1 66 98.5%

Prostate cancer MAKNA 96 0 2 98 97.9%

Lymphoma MAKNA 82 0 2 84 97.62%

Colon cancer MAKNA 124 2 2 128 96.9%

Leukaemia MAKNA 117 2 2 121 96.7%

Lung cancer MAKNA 111 2 2 115 96.5%

Breast cancer MAKNA 136 3 2 141 96.4%

Nasopharyngeal cancer MAKNA 76 1 3 79 96.2%

Cervical cancer (#2) MAKNA 87 2 2 91 95.6%

Mouth cancer MOH 23 1 1 25 92.0%

Total 917 13 19 948

Percentage 96.7% 1.3% 2.0%

Description of a pamphlet that relies on logos

The first pamphlet selected to demonstrate the reliance on logos is the NPC pamphlet consisting of six panels. Figure 1 shows panels 1 and 2 of the NPC pamphlet produced by MAKNA.

Panel 1 has the headline “Nasopharyngeal Cancer” and “Kanser nasofarinks”. The body text (“A little knowledge means everything” and “Understand the facts early”) makes it clear that the pamphlet will be informative as it stresses “knowledge” and “facts”. On the top right-hand corner is the logo of MAKNA (a pink hibiscus flower) and the words “MAKNA”, “Majlis Kanser Nasional”, “National Cancer Council”, and the organisation tagline (“A meaning to life”). Here ethos is used to tell the audience that the pamphlet is from a trusted source.

Panel 2 headline “WHAT IS NASOPHARYNGEAL CANCER? (NPC)” uses the logical appeal to edu-cate the audience on the location of the nasopharynx, the growth of abnormal cells in the area, and Epstein-Barr virus as a major cause of NPC. More facts on NPC incidence in Malaysia are shown in a table.

Figure 2 shows panels 3 and 4 of the NPC pamphlet produced by MAKNA. Panel 3 uses the logos appeal by explaining the possible causes of NPC. NPC is caused by the growth of abnormal cells, shown in a microscope picture. The external causes are explained in the middle section headlined “NPC Risk Factors”, which highlights Asians with a high salted fish and meat diet, and people who inherited certain tissue types to have higher risk. The pamphlet hedges these risk messages, such as “typically consume diets ...”, “increased risk of developing NPC”, and “more likely to get this cancer”. The bottom one-third of Panel 3 informs the audience of the three steps in “NPC Diagnosis Proce-dures” to lessen their fear of the unknown and to motivate them to seek cancer screening. The last bullet point switches focus to the prevalence of the cancer (“5th common cancer in Malaysia”) and the higher susceptibility of males to NPC (“3rd most common cancer in males”).

Panel 4 also uses logos to present information on “NPC Treatment” and “NPC Follow-up Treatment”. The picture of a scientist looking through a microscope suggests that she may be seeing abnormal cells shown on Panel 3. Indirectly this image enhances the authority of the information by suggesting that the facts provided in the pamphlet are based on scientific research. In the body text on “NPC Fol-low-up Treatment” there is a sudden switch from third-person point of view to a second-person point of view to encourage the audience to seek medical attention (“If you have any problems or notice any new symptoms between these times, consult your doctor as soon as possible”). The use of the pro-noun “you” reflects the pathos appeal because it speaks directly to the audience about their uncertain-ty as to whether they have NPC.



Panels 5 and 6 are a repeat of Panels 2-4 in Malay. However, the equivalent sentence uses the sec-ond-person pronoun “anda” only once (“Sekiranya terdapat sebarang masalah ataupun tanda-tanda baru sepanjang tempoh ini, sila hubungi doktor anda secepat mungkin”). This is because in the Eng-lish version, the second-person pronoun is used in the conditional clause which is written in the active voice (“If you have any problems ...”). The audience is the subject of the clause, placing responsibility of them to do something should suspicious signs appear. However, in the Malay version the condi-tional clause is written in the passive voice (“Sekiranya terdapat sebarang masalah ...”), highlighting the object (i.e. problems). The subject of the clause is hidden, making the message less forceful on the agency. At the bottom of Panel 6, the logo and name and address of MAKNA are provided in a centred position, reinforcing the authoritativeness of the information in the pamphlet, reflecting the ethos appeal. Aristotle (1954, p. 1356a) considers ethos or the moral character to be “the most effec-tive means of proof” (as cited in Mori, 2016, p.65).

Overall, the NPC pamphlet is informative and relies on logos. Numerical data and facts are used to provide information on susceptibility and recommended actions. The pamphlet presents a matter-of-fact way of dealing with NPC, by suggesting that the public should go for screening to find out if they have the cancer. If they already have the cancer, the pamphlet suggests three types of treatment for the cancer. The ethos appeal is anchored to the authority of MAKNA as an organisation recognised by the Ministry of Health to assist in creating public awareness of cancer. It taps into what is known about MAKNA and its role to provide aid to cancer patients, including conducting mammogram screenings, and outreach and awareness activities (MAKNA, 2017). There is an obvious absence of pathos in the NPC pamphlet, mainly due to the absence of disease severity information. Advanced symptoms of NPC are omitted such as blood-tinged secretion, nasal obstruction and sometimes epistaxis, as well as fullness, hearing loss and tinnitus (Fles, 2016). Advanced stage symptoms such as headache, di-plopia, facial pain and numbness including eye symptoms such as strabismus and lagophthalmos, and an obvious neck mass (Fles, 2016) are also omitted. The only piece of information that can be con-strued as disease severity in the NPC pamphlet is “These abnormal cell growths form tumours that can subsequently spread to other parts of the body” but since the description is at the microscopic level and not visible to the naked eye, the severity may be lost on a non-medically informed audience. The absence of severity information in the form of early symptoms of NPC may cause the pamphlet to be less effective in motivating the public to seek cancer screening because they may not know that the non-specific conditions they experience can be early signs of NPC. NPC is usually detected in ad-vanced stages, resulting in high fatality rates. Malaysian statistics show that 63% and 60% of male and female cases respectively were detected at Stages 3 and 4 (Ministry of Health, Malaysia, 2017). Omitting disease severity information may reflect positive appeal but research has shown that using the negative or fear appeal is more effective in health messages (Robberson & Rogers, 1988) to frighten the audience into taking action.

Description of a mouth cancer pamphlet showing some use of pathos

The second pamphlet selected is a mouth cancer pamphlet produced by MOH in Malay (Figures 4 and 5). This pamphlet illustrates the complementary use of text and images to present cancer risk infor-mation and assumes that if the audience does not read the words, they will still get some information on mouth cancer from the images.

Panel 1 has the words “Kanser Mulut” (Mouth Cancer) on the cover of the pamphlet, accompanied by a photograph of a tongue with a growth on it, indicated by a yellow arrow. At the bottom of the panel is the MOH logo and name at the bottom, marking ethos appeal and assuring the audience that the pamphlet is from a trusted source and the information provided is reliable.

Panel 2 has the headline “Kanser Mulut” in red font to draw attention to the facts which follow. The logos appeal is used throughout: the first paragraph describing what mouth cancer is, and early signs such as swelling, ulcer and colour changes (“kebengkakan, ulser dan perubahan warna”); the second paragraph highlighting risk factors (practices and age); and the last part on risk factors. The audience are asked to avoid tobacco products, betel nuts, tobacco leaves, and excessive alcohol. This part indirectly provides susceptibility information on the risk groups, that is, people who have such practices.

Panel 3 is a continuation of Panel 2. Both panels 2 and 3 use the logos appeal by educating the audience with facts on risk factors and recommended actions to reduce risk of mouth cancer and to



detect it early. The heading (“Amalkan pemakanan dan cara hidup sihat”, meaning “Practise a healthy diet and lifestyle”) is followed by three bullet points advocating regular checks of the mouth, teeth and mouth hygiene, and a fibre-rich diet. The background picture of a doctor performing surgery on a patient (which stretches across both panels) suggests that if these practices are not adopted, then the audience may get mouth cancer and end up on the operating table.

Panel 4 illustrates how the six images complement the textual information to show the sites of the mouth cancer, that is, on the tongue, on the cheeks, below the tongue, and on the gum, palate, and lips.. The focus on facts is clear from the heading “Kanser mulut sering berlaku di bahagian tertentu dalam mulut seperti ...” (Mouth cancer often occurs in certain parts of the mouth like ...).

Panel 5 advocates early detection and treatment, and achieves this through logos. At the bottom of the panel is a photograph of a woman checking her mouth. The answer on what to look for is provided in the text, that is, red and white spots in the mouth, mouth ulcers that do not give pain and easily bleed, growth, and changes in sense of taste.

Finally Panel 6 demonstrates the rare use of pathos. It tells the audience to see a dentist if they suspect they have mouth cancer, reinforced through a photograph of a dentist examining a patient’s mouth. The mouth cancer pamphlet ends with a clear emotional appeal: “Pengesanan awal kanser mulut boleh menyelamatkan nyawa anda” (Early detection of mouth cancer can save your life). The suggestion that mouth cancer may lead to death uses the fear appeal to motivate the audience to seek cancer screening.

The MOH mouth cancer pamphlet shows a good use of text and images to educate the public on risk factors, disease severity and early detection measures using logos. The photographs are used to im-print images of the early signs of cancer in the audience’s minds and create fear in the process. The only other pamphlet that uses photographs is the cervical cancer pamphlet produced by CIM, but the photographs are of the cancer cells which may not carry much meaning for a non-medically informed audience. Similarly, MAKNA cancer pamphlets use science-oriented illustrations such as anatomical diagrams, microscope pictures and photographs of scientists looking through microscopes. The sci-ence-oriented images may be hard for the lay public to understand but they lend credibility to the can-cer risk messages conveyed in textual form. To evoke emotional responses to urge the audience to undertake cancer screening, photographs of deformity caused by abnormal cell growth like those shown in the mouth cancer pamphlet are probably more effective than science-oriented images.

Discussion and Conclusion

The analysis of cancer pamphlets demonstrated a reliance on logos to provide information on risk fac-tors, causes, symptoms, and treatment options. There is an obvious lack of pathos, which may sub-tract from the pamphlets’ persuasiveness to motivate the public to undertake preventive measures or cancer screening. However, the near absence of pathos is not surprising considering Ting and Je-rome’s (2017) finding on airport banners on infectious diseases where an appeal to love for family was evident in only one poster on the hand, foot and mouth disease. The results of the present study differ from Jerome and Ting’s (2017) findings on the use of the fear, guilt and pity appeals in hospital post-ers on cancer. In the present study, eight of the pamphlets were produced by MAKNA which used a template. The only place where an emotional appeal can be inserted is in panel 1. The NPC pamphlet stresses facts (“Understand the facts early”) but five other pamphlets make an emotional appeal here: (1) breast cancer: “Save your life, Spot it early”; (2) lung cancer: “It could start from your next puff”; (3) cervical cancer: “A screening may save your life”; (4) colon cancer: “The killer from within”; and (5) children leukaemia: “The curable childhood killer”. Examples (4) and (5) use the negative appeal which is more persuasive in health messages than the positive appeal, seen in Examples (1) and (3) (Robberson & Rogers, 1988). More appeals to the audience’s feelings should be made in cancer risk messages because pathos has been found to be the most effective mode of persuasion in advertise-ments (Ab Rashid et al., 2016; Emanuel et al., 2015; Nair & Ndubisi, 2015; Winn, 2000) and political speeches (Androniciuc, 2016; Mori, 2016; Mshvenieradze, 2013). Facts and statistics provide aware-ness at the knowledge level but may not motivate the public to enact recommended actions because they may not sense the urgency for early cancer detection.

In addition, the study revealed that the ethos appeal lies in the authority of the government agency that produced the pamphlet. None of the cancer pamphlets use anecdotal accounts of cancer survi-vors. Survivor narratives constituting personal experiences of ordinary human beings can speak loud-



er than facts and statistics. Narratives can be a kind of support for patients and cancer survivors to make sense of their cancer experience (Freda & Martino, 2015; Green, 2006; Kreuter et al., 2008).

The study revealed an over-dependence on the rational appeal in cancer pamphlets. The study did not examine how agency in the cancer risk messages affect the audience’s intention to make lifestyle changes to minimise disease threat (Bell et al., 2014a, 2014b; Chen et al., 2015; McGlone et al., 2013). Further research should investigate linguistic framing of cancer risk messages, particularly how use of personal pronouns and frightening images and messages can increase intention to undertake preventive or cancer screening measures.

Acknowledgement

This study is funded by the Ministry of Education, Malaysia via the Transdisciplinary Research Grant Scheme (TRGS) awarded to the project on “Constructing a model for predicting public receptivity to-wards communication of biomedical and financial risk messages on nasopharyngeal cancer in Malay-sia”, Grant no. TRGS: C09/TRGS/1519/2016,

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Appendix

Figure 1. Panels 1 and 2 of an NPC Pamphlet (Source: MAKNA)



Figure 4. Panels 1-3 of a mouth cancer pamphlet (Source: MOH)



Figure 5. Panels 4-6 of a mouth cancer pamphlet (Source: MOH)

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